Temporal trends and variability of colonoscopy performance in a gastroenterology practice

Background and study aim: Quality measures for colonoscopy are operator dependent and vary. It is unclear whether quality measures change over time. In this study, time-dependent variation in colonoscopy performance was examined in a gastroenterology practice.

Patients and methods: Colonoscopy and histopathology records that were collected at three hospitals (one university and two non-university hospitals) over three time periods (2007, 2010, and 2013) were reviewed. Data from colonoscopists performing at least 100 procedures per year were analyzed. Inter-colonoscopist variation in performance (i. e. adjusted cecal intubation rate [aCIR], adenoma detection rate [ADR], advanced ADR, mean adenomas per procedure [MAP], proximal ADR, nonpolypoid ADR, and serrated polyp detection rate) were examined using coefficients of variation. Logistic regression analyses were also performed, adjusting for covariates.

Results: A total of 23 colonoscopists performing 6400 procedures were included. Overall, the mean aCIR, ADR, MAP, and proximal ADR improved significantly over time, from 91.9 %, 22.5 %, 0.37, and 10.2 % in 2007 to 95.3 %, 25.8 %, 0.45, and 13.4 %, respectively, in 2013 (P < 0.05). The inter-colonoscopist variation in ADR decreased from 37 % in 2007 to 15 % in 2013 (P < 0.05). In the non-university hospitals, mean values for quality measures increased significantly over time, whereas they remained stable in the university hospital.

Conclusions: Variability in performance among colonoscopists decreased significantly within the gastroenterology clinical practice. Core quality measures improved over time, mainly through improvement of the lower performers. Measurement of inter-colonoscopist variation in performance helps to identify factors that stimulate or hinder performance, and forms the basis for interventions.

Trial registration: http://www.trialregister.nl.

^* These authors contributed equally to this work.

• References

• 1 Nishihara R, Wu K, Lochhead P et al. Long-term colorectal-cancer incidence and mortality after lower endoscopy. N Engl J Med 2013; 369: 1095-1105
• 2 Brenner H, Chang-Claude J, Seiler CM et al. Protection from colorectal cancer after colonoscopy: a population-based, case-control study. Ann Intern Med 2011; 154: 22-30
• 3 Lakoff J, Paszat LF, Saskin R et al. Risk of developing proximal versus distal colorectal cancer after a negative colonoscopy: a population-based study. Clin Gastroenterol Hepatol 2008; 6: 1117-1121
• 4 European Colorectal Cancer Screening Guidelines Working G. von Karsa L, Patnick J et al. European guidelines for quality assurance in colorectal cancer screening and diagnosis: overview and introduction to the full supplement publication. Endoscopy 2013; 45: 51-59
• 5 Kaminski MF, Regula J, Kraszewska E et al. Quality indicators for colonoscopy and the risk of interval cancer. N Engl J Med 2010; 362: 1795-1803
• 6 Corley DA, Jensen CD, Marks AR et al. Adenoma detection rate and risk of colorectal cancer and death. N Engl J Med 2014; 370: 1298-1306
• 7 Baxter NN, Sutradhar R, Forbes SS et al. Analysis of administrative data finds endoscopist quality measures associated with postcolonoscopy colorectal cancer. Gastroenterology 2011; 140: 65-72
• 8 Rex DK, Bond JH, Winawer S et al. Quality in the technical performance of colonoscopy and the continuous quality improvement process for colonoscopy: recommendations of the U.S. Multi-Society Task Force on Colorectal Cancer. Am J Gastroenterol 2002; 97: 1296-1308
• 9 Barclay RL, Vicari JJ, Doughty AS et al. Colonoscopic withdrawal times and adenoma detection during screening colonoscopy. N Engl J Med 2006; 355: 2533-2541
• 10 Lee TJ, Rutter MD, Blanks RG et al. Colonoscopy quality measures: experience from the NHS Bowel Cancer Screening Programme. Gut 2012; 61: 1050-1057
• 11 Bressler B, Paszat LF, Chen Z et al. Rates of new or missed colorectal cancers after colonoscopy and their risk factors: a population-based analysis. Gastroenterology 2007; 132: 96-102
• 12 Coe SG, Crook JE, Diehl NN et al. An endoscopic quality improvement program improves detection of colorectal adenomas. Am J Gastroenterol 2013; 108: 219-226
• 13 Shaukat A, Oancea C, Bond JH et al. Variation in detection of adenomas and polyps by colonoscopy and change over time with a performance improvement program. Clin Gastroenterol Hepatol 2009; 7: 1335-1340
• 14 Corley DA, Jensen CD, Marks AR. Can we improve adenoma detection rates? A systematic review of intervention studies. Gastrointest Endosc 2011; 74: 656-665
• 15 Gavin DR, Valori RM, Anderson JT et al. The national colonoscopy audit: a nationwide assessment of the quality and safety of colonoscopy in the UK. Gut 2013; 62: 242-249
• 16 Brenner H, Altenhofen L, Kretschmann J et al. Trends in adenoma detection rates during the first 10 y of the German Screening Colonoscopy Program. Gastroenterology 2015; 149: 356-66.e1
• 17 Sanduleanu S, Rondagh EJ, Masclee AA. Development of expertise in the detection and classification of non-polypoid colorectal neoplasia: experience-based data at an academic GI unit. Gastrointest Endosc Clin N Am 2010; 20: 449-460
• 18 National Institute for Public Health and the Environment. Bowel cancer screening programme. Available from: http://www.rivm.nl/en/Topics/B/Bowel_cancer_screening_programme Accessed: 8 December 2015
• 19 Aronchick CA, Lipshutz WH, Wright SH et al. Validation of an instrument to assess colon cleansing. Am J Gastroenterol 1999; 94: 2667
• 20 [Anonymous]. The Paris endoscopic classification of superficial neoplastic lesions: esophagus, stomach, and colon: November 30 to December 1, 2002. Gastrointest Endosc 2003; 58: 3-43
• 21 Lieberman D, Nadel M, Smith RA et al. Standardized colonoscopy reporting and data system: report of the Quality Assurance Task Group of the National Colorectal Cancer Roundtable. Gastrointest Endosc 2007; 65: 757-766
• 22 Pitman EJG. A note on normal correlation. Biometrika 1939; 31: 9-12
• 23 Wang HS, Pisegna J, Modi R et al. Adenoma detection rate is necessary but insufficient for distinguishing high versus low endoscopist performance. Gastrointest Endosc 2013; 77: 71-78
• 24 Kahi CJ, Hewett DG, Norton DL et al. Prevalence and variable detection of proximal colon serrated polyps during screening colonoscopy. Clin Gastroenterol Hepatol 2011; 9: 42-46
• 25 Kahi CJ, Vemulapalli KC, Johnson CS et al. Improving measurement of the adenoma detection rate and adenoma per colonoscopy quality metric: the Indiana University experience. Gastrointest Endosc 2014; 79: 448-454
• 26 Sedlack RE, Shami VM, Adler DG et al. Colonoscopy core curriculum. Gastrointest Endosc 2012; 76: 482-490
• 27 Steele R, Rey J, Lambert R. European guidelines for quality assurance in colorectal cancer screening and diagnosis. Professional requirements and training. Endoscopy 2012; 44: E106-115
• 28 Hassan C, Bretthauer M, Kaminski MF et al. Bowel preparation for colonoscopy: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy 2013; 45: 142-150
• 29 Rondagh EJ, Bouwens MW, Riedl RG et al. Endoscopic appearance of proximal colorectal neoplasms and potential implications for colonoscopy in cancer prevention. Gastrointest Endosc 2012; 75: 1218-1225
• 30 McGill SK, Kaltenbach T, Friedland S et al. The learning curve for detection of non-polypoid (flat and depressed) colorectal neoplasms. Gut 2015; 64: 184-185
• 31 Radaelli F, Meucci G, Sgroi G et al. Technical performance of colonoscopy: the key role of sedation/analgesia and other quality indicators. Am J Gastroenterol 2008; 103: 1122-1130
• 32 Rex DK, Schoenfeld PS, Cohen J et al. Quality indicators for colonoscopy. Gastrointest Endosc 2015; 81: 31-53
• 33 Denis B, Sauleau EA, Gendre I et al. The mean number of adenomas per procedure should become the gold standard to measure the neoplasia yield of colonoscopy: a population-based cohort study. Dig Liver Dis 2014; 46: 176-181
• 34 le Clercq CC, Bouwens MW, Rondagh EJ et al. Postcolonoscopy colorectal cancers are preventable: a population-based study. Gut 2014; 63: 957-963
• 35 Do A, Weinberg J, Kakkar A et al. Reliability of adenoma detection rate is based on procedural volume. Gastrointest Endosc 2013; 77: 376-380
• 36 Rajasekhar PT, Rees CJ, Bramble MG et al. A multicenter pragmatic study of an evidence-based intervention to improve adenoma detection: the Quality Improvement in Colonoscopy (QIC) study. Endoscopy 2015; 47: 217-224